Fluency Direct

With Computer-Assisted

Physician Documentation (CAPD)

REDEFINING CLINICAL DOCUMENTATION WITH REAL-TIME PHYSICIAN FEEDBACK

 

In today’s complex and dynamic healthcare environment, organizations are challenged with a seemingly endless list of competing priorities. Consequently, the pressures on physicians to create clinical documentation to meet new standards of accountability, reimbursement, patient care and quality reporting are rapidly increasing.

M*Modal Fluency Direct™ Speech To Text facilitates better documentation in EHRs and delivers content-based, clinically-driven feedback at the time of report creation with its built-in Computer-Assisted Physician Documentation (CAPD) functionality. By helping physicians create better documentation at the time of reporting, M*Modal increases the likelihood of the diagnosis and care provided being accurately captured for improved patient outcomes and reimbursement.

Completely integrated into the physician clinical documentation process, M*Modal CAPD automates the identification of the most common documentation deficiencies and specificity queries in notes created via templates, typing and/or speech. M*Modal CAPD then automatically generates feedback to the physician, asking for additional information or clarification when appropriate. By monitoring and improving documentation at the time of its creation, M*Modal helps physicians create higher-quality reports without compromising on workflow or productivity. Moreover, this automatic chart review helps educate physicians to document appropriately for clinical care,
iamge1coding and compliance instead of merely generating interruptive alerts.

Uniquely, all M*Modal solutions are built on a single platform leveraging both M*Modal Speech Understanding™ and Natural Language Understanding (NLU) technologies, which are delivered across multiple solutions.

M*Modal Speech Understanding allows for the sharing of speech profile information across applications and workflows. This means that a single trained speech profile can be leveraged for frontend speech and back-end transcription or used in mobile applications. One profile allows all speech-enabled documentation With Computer-Assisted Physician Documentation (CAPD) ENABLE PHYSICIAN EDUCATION By giving physicians real-time feedback on document completeness, M*Modal CAPD effectively educates them on evolving documentation requirements from a CDI, ICD-10 and clinical perspective, without adding to their demanding schedules by: • Increasing physician proficiency in proper documentation, which would consequently reduce the number and frequency of inquires for clarification • Identifying the most challenging documentation areas and reporting on which physicians have the greatest difficulties • Matching individual physicians with notifications that are most pertinent and valuable to them IMPROVE QUALITY OF DOCUMENTATION Fluency Direct with CAPD constantly improves the accuracy of clinical documentation by delivering contextspecific, clinically-relevant information for needed details or clarifications as the report is being created. • Consider a physician dictating a note that mentions unspecified chronic congestive heart failure (CHF) • The system will generate feedback asking for the necessary clarification on acuity (acute vs. chronic) and type (systolic vs. diastolic) • If the physician chooses to address the identified deficiency, the related message automatically disappears • Or if the physician chooses to ignore the message, no further action is required, but the dismissal is tracked and can be audited methods to contribute to each other’s success. As you use traditional transcription, you are actually teaching Fluency Direct. As you use Fluency Direct and transcription, you are simultaneously making your mobile experience better.

Moreover, the very same clinical understanding utilized for CAPD can also be used with Fluency Discovery™ for back-end HIM and CDI workflows, without additional configurations. This allows users to leverage the single platform to identify and correct deficient documentation in real-time, concurrently and/or retrospectively. Organizations can start with a retrospective look at their documentation to pre-determine the impact specific feedback would have on individual physicians before going live with CAPD for maximum effectiveness with minimum disruption.

IMPROVE QUALITY OF DOCUMENTATION

Fluency Direct with CAPD constantly improves the accuracy of clinical documentation by delivering contextspecific, clinically-relevant information for needed details or clarifications as the report is being created.

  • Consider a physician dictating a note that mentions unspecified chronic congestive heart failure (CHF)
  • The system will generate feedback asking for the necessary clarification on acuity (acute vs. chronic) and type (systolic vs. diastolic)
  • If the physician chooses to address the identified deficiency, the related message automatically disappears
  • Or if the physician chooses to ignore the message, no further action is required, but the dismissal is tracked and can be audited

ENABLE PHYSICIAN EDUCATION

By giving physicians real-time feedback on document completeness, M*Modal CAPD effectively educates them on evolving documentation requirements from a CDI, ICD-10 and clinical perspective, without adding to their demanding schedules by:

  • Increasing physician proficiency in proper documentation, which would consequently reduce the number and frequency of inquires for clarificationimage2
  • Identifying the most challenging documentation areas and reporting on which physicians have the greatest difficulties
  • Matching individual physicians with notifications that are most pertinent and valuable to them

FACILITATE APPROPRIATE REIMBURSMENT AND ICD-10 TRANSITION

By continuously analyzing, monitoring and improving documentation from a coding and CDI perspective, M*Modal supports ICD-9 and lays the foundation for the transition to ICD-10. It also:

  • Significantly augments CDI programs to keep revenue cycles steady
    and reimbursements flowing during the transition

 

  • Minimizes the compounding effect of deficient documentation that creates downstream inefficiencies and delays

INCREASE PRODUCTIVITY

 

By engaging physicians at the time they are documenting patient care through an early clarification process, M*Modal CAPD improves the overall productivity of multiple stakeholders. It also:

  • Accommodates both the physician’s preferred documentation method—whether it be templates, typing or speech—while also considering the organization’s need for more complete charts and structured data

 

  • Improves physician productivity by minimizing disruptive and time-consuming queries by coders long after the original note was created

 

  • Minimizes downstream, manual query processes and increases the
    effectiveness of CDI specialists and coders

 

PROMOTE BETTER PATIENT CARE

 

M*Modal gives physicians the tools they need to draw a complete and accurate clinical picture in the patient documentation. Automatic chart review facilitated by CAPD also:

  •  Improves the speed and access to more accurate and complete clinical information to reduce errors

 

  • Promotes evidence-based medicine

 

  • Supports consistency and standardization in documentation practices by continually applying the same rules across all physicians, patients and documents

 

  • Brings the clarification process to the time of report creation when the patient encounter is fresh in the physician’s mind, not days later when details may not be correctly or completely recalled

 

 

FEATURES

 

  • Embedded functionality of Fluency Direct to deliver automated feedback based on continuous, real-time evaluation of text being createD
  • Automated identification of the most common documentation issues
  • NLU technology used to support compliance, document quality and patient care
  • True real-time clinical understanding of content and context as physicians dictate, type or use templates
  • Advanced adaptability and customization with the ability to match physicians with specific feedback and configure new feedback rules
  • Audit trail of notifications to specific physicians and their clarification rates for monitoring over time and ongoing improvement
  • In-house M*Modal Adoption Services to provide clinical documentation expertise to help identify the most effective feedback, enable physician adoption and monitor usage
  • Non-interruptive, high-value, accurate, reliable and appropriate physician feedback

FEATURES

 

  • Improves the quality of documentation at the time of report creation, enabling more accurate coding and more appropriate reimbursement
  • Promotes an information-driven, consistent and reliable approach to physician documentation
  • Significantly boosts physician productivity, efficiency, education and satisfaction • Minimizes retrospective queries, extends CDI programs and streamlines downstream workflows
  • Helps meet documentation needs related to ICD-9, ICD-10, CDI, Quality Reporting, ACOs, etc.
  • Reduces legal exposure and risk of audits
  • Facilitates improved medical communication and collaborative care with closed-loop clinical documentation

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